Provider Demographics
NPI:1336256411
Name:MEDRZYCKI, ROBERT ADAM (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ADAM
Last Name:MEDRZYCKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:248 TOM HILL SR BLVD
Mailing Address - Street 2:# 331
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1815
Mailing Address - Country:US
Mailing Address - Phone:478-471-1004
Mailing Address - Fax:478-471-1048
Practice Address - Street 1:3200 RIVERSIDE DR
Practice Address - Street 2:SUITE 300-A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2550
Practice Address - Country:US
Practice Address - Phone:478-471-1004
Practice Address - Fax:478-471-1048
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ64059Medicare ID - Type Unspecified